*I affirm and attest that I am the stated individual pertaining to this document and all information contained in this document is true, correct, current, and complete in all respects to the best of my ability. I accept the responsibility to keep the Correct Care Inc. advised of any change or appropriate addition to any information contained in this form. **I affirm and attest that I am the stated individual pertaining to this document and all information contained in this document is true, correct, current, and complete in all respects to the best of my ability. I accept the responsibility to keep the Correct Care Inc. advised of any change or appropriate addition to any information contained in this form.